no slide title · 2013-11-26 · incidence/mortality/morbidity occur in 70-80% of all multi-trauma...

Musculoskeletal Trauma

Humaryanto

Incidence/Mortality/Morbidity

Occur in 70-80% of all multi-trauma patients

Blunt or Penetrating

Upper extremity rarely life-threatening

– may result in long-term impairment

Lower extremity associated with more severe injuries

– possibility of significant blood loss

– femur, pelvic injuries may pose life-threat

Incidence/Mortality/Morbidity

Problem is not just the bone injury

– Other injuries caused by the injured bone

» Soft tissue

» Vascular

» Nervous system

» Decreased function

Prevention Strategies

Sports Training

Seat Belt use

Child Safety Seat use

Airbag use

Gun Safety and Education

Motorcycle education and protective equipment

Fall prevention

Can you think of others?

Musculoskeletal System Function

Scaffolding/Support

Protection of vital organs

Locomotion

Production of RBC

Storage of minerals

Musculoskeletal Structures

Skin

Muscles

Bones

Tendons

Ligaments

Cartilage

Musculoskeletal Structures - Skin

Holds all structures together

Barrier function

Protects underlying structures

Subcutaneous tissue

– Fat

– Fascia

Further discussion in Soft-Tissue Trauma

Musculoskeletal Structures - Muscle

Composed of specialized cells with ability to contract

Voluntary (Skeletal)

– Conscious control

– Allows mobility

Smooth (Bronchi, GI tract, blood vessels)

– Controlled by ANS

– Able to alter inner lumen diameter

Cardiac

– Contracts rhythmically on its own

Musculoskeletal Structures - Muscle

Can only contract

Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands

Musculoskeletal Structures

Tendons

– Bands of connective tissue binding muscles to bones

Cartilage

– Connective tissue covering the epiphysis

– Surface for articulation

Ligaments

– Connective tissue supporting joints

– Attach bone ends to each other

Bones

Living tissue

Consists of cells which deposit calcium, phosphorus on protein matrix

Constantly remodels itself

Able to repair damage without formation of scar tissue

Bones

Structural form for body

Protection

Point of attachment for tendons, ligaments, cartilage and muscles

Allows for movement

Storage of minerals

Produce red blood cells

Skeletal System Components

Axial Skeleton

– forms the central axis of the body

– includes skull, vertebral column, bony thorax

Appendicular Skeleton

– limbs

Pectoral girdle

– bones that attach the upper limbs to the axial skeleton

Pelvic girdle

– paired bones of the pelvis that attach the lower limbs to the axial skeleton and sacrum

Long Bone Anatomy

Diaphysis

– Long, narrow shaft

– Dense, compact bone

Metaphysis

– Head of bone

– Between epiphysis and diaphysis

Medullary canal

– Contains marrow

Long Bone Anatomy

Periosteum

– Outer fibrous covering

– Allows for increase in diameter

– Vascular

– Nerves

Epiphysis

– Articulated, widened end

– Allows bone to lengthen

– Cancellous bone with red blood marrow

– Weakest point in child’s bone

Joints

Points of articulation between bones

Fused/Fibrous

– Sutures

» Between bones of skull

Synovial

– Fluid filled chamber which lubricates articulated surfaces

– Allow for movement

» gliding, flexion, extension, abduction, adduction, circumduction, rotation

Synovial Joints

Ball/Socket

–Shoulder/Hip

Hinge

–Elbow/Knees/Fingers/TMJ

Pivot

–Between radius and ulna

Gliding

–Bones of wrist

Fracture

Break in continuity of bone

Closed

– Overlying skin intact

Open

– Wound extends from body surface to fracture site

– Produced either by bones or object that caused Fx

– Danger of infection

– Bone end not necessarily visible

Mechanism of Injury

Direct

– Break occurs at point of impact

Indirect

– Force is transmitted along bone

– Injury occurs at some point distant to point of impact

– Femur, hip, pelvic fracture due to knees hitting dash

Mechanism of Injury

Twisting

– Distal limb remains fixed

– Proximal part rotates

– Shearing, fracturing occur

– Football. skiing accidents

Avulsion

– Muscle and tendon unit with attached fragment of bone ripped off bone shaft

Mechanism of Injury

Stress

– Occur in feet secondary to prolonged running or walking

Pathological

– Result of Fx with minimal force

– Cancer, osteoporosis

Fracture Descriptions

Open vs Closed

X-Ray descriptions

– greenstick

– oblique

– transverse

– comminuted

– spiral

– impacted

– epiphyseal

Fracture Types

Transverse

– Cuts shaft at right angle to long axis

– Often caused by direct injury

Greenstick

– Pliable bone splinters on one side without complete break

– Occurs in children

Fracture Types

Spiral

– Fx site coils through bone like spring

– Occurs with torsion

Oblique

– Occurs at angle to long axis of shaft

Comminuted

– Bone broken into 3 or more pieces

Fracture Type

Impacted

– Bone ends jammed together

– Occurs with compression

– Frequently no loss of function

Problems Associated with Musculoskeletal Injuries

Hemorrhage

Interruption of Blood Supply

Disability

Instability

Soft Tissue injury

Complications associated with Fractures

Hemorrhage

– Possible loss within first 2 hours

» Tib/Fib - 500 ml

» Femur - 500 ml

» Pelvis - 2000 ml

Interruption of Blood Supply

– Compression on artery

» decreased distal pulse

– Decreased venous return

Complications associated with Fractures

Disability

– Diminished sensory or motor function

» inadequate perfusion

» direct nerve injury

Specific Injuries

– Dislocation

– Amputation/Avulsion

– Crush Injury (soft tissue trauma discussion)

Sprains/Strains

Sprain

– tearing of ligaments surrounding joint

Strain

– overstretching of muscle or tendon

Musculoskeletal Assessment

The possibilities

– Life-threatening injuries or conditions, including life/limb threatening musculoskeletal trauma

– Life/Limb threatening injuries and only simple musculoskeletal trauma

– Life/Limb threatening musculoskeletal trauma and no other life/limb threatening injuries

– Only isolated, non-life/limb threatening injuries


Initial Assessment

– ABCDs

– Life threats managed first

– Don’t overlook life/limb threatening musculoskeletal trauma

– Don’t be distracted by “gross” but non-life/limb threatening musculoskeletal injury


With few exceptions orthopedic injuries are not life threatening.

Do not let drama of obvious or grossly deformed fracture distract you

from more serious problems involving ABC’s


The six “P”s of musculoskeletal assessment

– Pain

» on palpation

» on movement

» constant

– Pallor - pale skin or poor cap refill

– Paresthesia - “pins and needles” sensation

– Pulses - diminished or absent

– Paralysis

– Pressure


Vascular injury should be suspected in all Fx’s/dislocations UPO

Evaluate with 5 P’s

– Pain

– Pallor

– Pulselessness

– Paresthesias

– Paralysis


History of Present Injury

– Where is pain felt?

– What occurred? What position was limb in?

– Were deceleration forces involved?

– Was there direct impact?

– Has there ever been previous trauma or Fx?


Palpation and Inspection

– Swelling/Ecchymosis

» Hemorrhage/Fluid at site of trauma

– Deformity/Shortening of limb

» Compare to other extremity if norm is questioned

– Guarding/Disability

» Presence of movement does not rule out fracture



– Tenderness

» Use two point fixation of limb with palpation with other hand.

» Tenderness tends to localize over injury site.

– Crepitus

» Grating sensation

» Produced by bones rubbing against each other.

» Do not attempt to elicit.



– Exposed bones

» Fx can be open without exposed bones

– Principal danger is not to bones, but to underlying neurovascular structures around bone.



– Distal to injury, assess:

» skin color

» skin temperature

» sensation

» motor function

– If uncertain, compare extremities

– When in doubt splint!


Because orthopedic injuries have low priority in multiple systems trauma, all Fx’s may not be found in field

Long Board

– Splints every bone and joint

– No loss of time

– Focus on critical conditions

Key Point

Orthopedic injuries are seldom immediately life threatening.

Tend to other issues first.

Only immediately life threatening orthopedic injury is Pelvic Fx due to potential massive

hemorrhage

Key Point

The problem is not the damage to the bone

The problem is the damage the bone does to the surrounding soft tissues.

Evaluate Neurovascular Function Distally

Management - General

Immobilization Objectives

– Prevent further damage to nerves/blood vessels

– Decrease bleeding, edema

– Avoid creating an open Fx

– Decrease pain

– Early immobilization of long bone fractures critical in preventing fat embolism


Principles of Fracture Management

– Splint joint above, below

– Splint bone ends

– Loosely cover open fracture sites

– Neurovascular assessment

» before and after splinting

– Gentle in-line traction of long bone

» maintain normal alignment if possible

» reduction of angulated fracture site


Principles of Fracture Management (cont)

– Position of function

– Pain management

Body Splinting

– In urgent patient, entire body is stabilized by using a long board

– Lower extremity fractures can be splinted as one to the long board

Splints, Padding, Bandages, Slings, and Swathes

Splints. Splints may be improvised from such items as boards, poles, sticks, tree limbs, rolled magazines, rolled newspapers, or cardboard. If nothing is available for a splint, the chest wall can be used to immobilize a fractured arm and the uninjured leg can be used to immobilize (to some extent) the fractured leg.


Padding. Padding may be improvised from such items as a jacket, blanket, poncho, shelter half, or leafy vegetation.

Bandages. Bandages may be improvised from belts, rifle slings, bandoliers, kerchiefs, or strips torn from clothing or blankets. Narrow materials such as wire or cord should not be used to secure a splint in place.


Slings. A sling is a bandage (or improvised material such as a piece of cloth, a belt and so forth) suspended from the neck to support an upper extremity. The triangular bandage is ideal for this purpose. Remember that the casualty's hand should be higher than his elbow, and the sling should be applied so that the supporting pressure is on the uninjured side.

Swathes. Swathes are any bands (pieces of cloth, pistol belts, and so forth) that are used to further immobilize a splinted fracture. Triangular and cravat bandages are often used as or referred to as swathe bandages. The purpose of the swathe is to immobilize, therefore, the swathe bandage is placed above and/or below the fracture--not over it.


Pain Management

– Avoid pain management until head/thoracic injury is ruled out

– Appropriate for isolated musculoskeletal injuries (fracture/sprain/dislocation)

– Underutilized

– Morphine sulfate titrated to pain relief without compromising adequate BP and ventilations

Management - Pediatric

Green stick Fx may go unrecognized

Fx can occur in epiphyseal plate, early closure can prevent further growth of affected bone

If no explanation from patient or parents or injury does not follow mechanism, suspect child abuse.

Oversight of volume loss when evaluating pt with multiple Fx’s

Estimate blood loss at each Fx site

Evaluation of neurovascular deficiencies in distal extremity

Management Error

Dislocations

Displacement of bone end from articulating surface at joint

Pain or pressure is most common symptom

Principal sign is deformity

May experience loss of motion of joint

Dislocations

Nerves, blood vessels pass very close to bone. Pressure on these structures can occur

Checking distally essential

– Pulse presence

– Pulse strength

– Sensation

Management - Dislocations

Principles of fracture/dislocation management

– Usually splinted in position of injury

– Neurovascular assessment before, after splinting

– Attempt realignment of dislocations if

» distal circulation is impaired

» long transport

– Discontinue realignment if pain increased significantly or resistance is encountered

– Immobilize proximal. distal joints and bones

– Analgesia, possible cold application

Sprains

Stretching. tearing of ligaments surrounding joint

Occur when joint is twisted beyond normal range of motion

Most common = Ankle

Sprain Management

Characteristics

– Pain

– Tenderness

– Swelling

– Discoloration

Typically does not manifest deformity

Ice, compression, elevation, immobilize

When in doubt, splint

Consider analgesia

Strains

Tearing, stretching of musculotendonous unit.

Spasm, pain on active movement

Usually no deformity, swelling

Pain present on active movement

Avoid active movement, weight bearing

Minor Musculoskeletal Injury Management

Cold/Heat application

– cold best if in first 48 hours to reduce swelling

– heat best if after 48 hours to increase circulation

– no direct application to soft tissue

» wrap in towel or gauze

Minor Musculoskeletal Injury Management

Other care

– Is immobilization/splinting needed?

– Is an X-ray needed?

– Is there a need for MD follow? ED visit?

– What type of transport is needed?

Traumatic Amputation

First priority - ABC’s

– Bleeding from stump usually not a problem

Next priority is to save limb

Traumatic Amputation Management

Control Bleeding

Elevate

Apply direct pressure to stump

Avoid tourniquet except as last resort

Traumatic Amputation - Limb Management

Place in saline moist gauze

Place in plastic bag

Place bag on ice

Do not

– Warm amputated part

– Place part in water

– Place directly on ice

– Use dry ice

Upper Extremity Fx

Proximal Humerus

– Usually from a fall on outstretched hand.

– Manage with sling, swathe

– Deltoid bulge often accentuated

Shaft of Humerus

– Usually obvious due to deformity

– Wrist drop may occur

– Vascular compromise may be present

Upper Extremity Fx

Colles Fx (silver fork)

– Distal radius

– Usually secondary to fall on outstretched hand

– Common in children

Figure-of-eight splint

Use the figure-of-eight splint to

treat fractures of the medial two-

thirds of the clavicle. Apply this

splint while the patient is erect,

with the hands on the iliac crests

and the shoulders held in

abduction. Wrap a stockinette or

padding snugly around both

shoulders. A premade version of

this splint is available. The figure-

of-eight splint loosens with time; a

simple sling may be used if

loosening of the splint is a concern

Shoulder Dislocation

Realignment

– One attempt if neurovascular compromise

– Do not attempt if associated with other severe injuries or spine injuries

– Provide analgesia

– Pull into anatomical position

Splinting

– Be creative

– Sling, swathe if possible

– Cravats are our friends!

Hip Dislocation

Anterior

– Blow to abducted leg, external rotation of affected extremity

Posterior

– Blow to flexed/Abducted knee

– More severe than anterior dislocation

– Associated with rupture of joint capsule, acetabular Fx, sciatic nerve injury

Management - Hip Dislocation

Realignment

– One attempt if severe neurovascular compromise

– Do not attempt if associated with other severe injuries

– Provide analgesia

– Steady and slow pull along shaft of femur

– If successful, “pops” into joint, sudden relief of pain, leg can easily return to extension

Immobilization

– Flexion of hip/knee for comfort acceptable

Pelvic Fracture

Direct or indirect force

Pelvic ring tends to break in two places

Bone fragments can cause damage

– Major vessels

– Urinary bladder

– Rectum resulting in contamination

– Nerves (Lumbrosacral plexus or sciatic)

Pelvic Injury

Introduction

– significant blood loss if bilateral

–may settle in retroperitoneal space

–3% of all fractures

–mortality 8 - 50%

–2nd most common cause of traumatic death

Pelvic Fracture

Signs & Symptoms

– pelvic instability

– pain (suprapubic also)

– crepitus

– bloody meatus

– neurovascular deficits

Polytrauma

Pelvis

Interventions

–Stable patient

»analgesia

»Repair vs mobilization

–Unstable patient

» Immobilize

»Ex-fix

»Angiography

embolization

Pemeriksaan fraktur pelvis

Tekan kearah posterior dan anterior pada krista iliaka (stabilitas anteroposterior)

Lakukan traksi pada salah satu tungkai dengan memfiksasi pelvis (stabilitas vertikal)

Pemeriksaan radiologis Bila keadaan pasien

memungkinkan segera dilakukan pemeriksaan foto pelvis AP

CT scan

3 dimensional CT

Radiographic examination

Outlet and inlet view

I

O

Pelvic Fx Management

Treat as potential critical trauma patient

Comfortable position if possible

Splint = Minimize movement

– Scoop stretcher

– Body to long board

– MAST for splint

Replace volume prn

– Possible 4000cc blood loss

– 2 IV of LR

Femur Fx

Femoral Neck (Hip)

– Most common in mid to late 60’s age group.

– Leg tends to rotate outward

» looks like anterior hip dislocation

– Minimal blood loss tends to occur due to joint capsule

Management

– NO traction splint

– long board, scoop or MAST

Femur Fx

Mid-Shaft

– Result from torsion in very young or old

– High speed deceleration with impact

» Hypovolemic shock

» Fat Embolism

– Early immobilization with traction splint will help prevent

– 1000 to 2000 cc blood loss

Femur Fx - Management

Assess for traction splint contraindications

May use PASG, secure to long board

– Secure to opposite extremity and then to long board (premise for the Sager splint)

Assess for :

– Soft tissue, vascular, or nerve injury

– Assess for hypovolemia

Femur Fx - Management

Traction Splints

– Used on mid-shaft femur fractures

– Do not use if suspected fracture involves

» proximal or distal 1/3 of femur

» pelvis

» hip (or hip dislocation)

» knee (or knee dislocation)

» ankle (or ankle dislocation)

– What if time (patient instability) does not allow for traction splint application?

Lower Extremity Fx

Patellar

– Due to direct impact

Tibia/Fibula

– High potential for:

» Open fracture

» Hemorrhage

» Infection

Calcaneal

– Results from falls (foot landing)

– High incidence of lumbar sacral compression

Management - Lower Extremity Fx

Patellar, Tibia/Fibula, and Calcaneal

– Assess for neurovascular impairment

– Realign long bones

– Splinting possibilities

» board splint or cardboard splint

» vacuum splint

» pillow

Elbow Dislocation

Presentation

– High neurovascular traffic

– Volkmann’s contracture - ischemia secondary to trauma causes ischemic contractions

Management

– assess for neurovascular impairment

– sling

– swathe

– analgesia and position of comfort

Knee Dislocation

Presentation

– Trauma to popliteal artery

– Many reduce spontaneously

– Knee dislocation has a 50% incidence of associated vascular injury

– Presence of distal pulse does not rule out vascular injury

Management - Knee Dislocation

Management

– Assess for neurovascular impairment

– One attempt at realignment if impairment or delayed transport

– Do not realign if associated with other severe injuries

– analgesia and position of comfort

– gentle, steady traction to move into normal position

» success by “pop” into joint, less deformity and pain, and increased mobility

Hemorrhage Management

Direct Pressure

– Most effective method

– Pressure bandage

Elevation

– Combination with direct pressure

Pressure Point

– Brachial, Femoral, Carotid

Tourniquet

– last resort

– rarely required

Tourniquet

Last resort, but do not wait too long.

Use flat wide material

BP cuff

Close to the wound as possible

Do not remove

Leave in plain view

Note time applied and clearly communicate during transfer of care

no slide title · 2013-11-26 · incidence/mortality/morbidity occur in 70-80% of all multi-trauma...

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